GOP revises ACA repeal bill likely headed for defeat

(Bloomberg) – Senators sponsoring a last-ditch Obamacare repeal bill scrambled to save it from near-certain death Sunday, circulating a new version aimed at winning over several GOP holdouts, according to two people familiar with the discussions.

Some of the changes, which come as Republicans face a Sept. 30 deadline to pass the measure, were designed to appeal to moderate holdouts like Lisa Murkowski of Alaska, while others appeared tailored to lure conservative skeptics like Rand Paul of Kentucky.

But with several senators expressing severe doubts or outright opposition to the version released last week, it’s unclear that the revisions will win enough support to resuscitate the repeal effort.

Sen. Susan Collins (R-Maine)

If Republicans can’t get the votes -- or decide to scrap this bill altogether -- it would mark another reminder of the party’s inability to deliver on seven years of promises to repeal the 2010 law.

The GOP could still try to resurrect a proposal later in the year, but the repeal effort’s collapse would seed doubts about the party’s ability to deliver any significant legislative victories.

On Sunday, even President Donald Trump seemed to concede that the outlook isn’t rosy for repeal. Asked by reporters about the health-care bill, he replied, “Eventually we will win on that. My primary focus, I must tell you -- has been from the beginning, as you can imagine -- is taxes.”

Targeting Key States

The new version GOP senators were circulating late Sunday, which could be presented at a Senate Finance hearing scheduled for Monday afternoon, would direct some additional funding to key states, including multiple provisions directing more money to Murkowski’s Alaska.

The revised bill also changes language regarding pre-existing conditions, which has been one of several flashpoints in the measure authored by Republicans Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.

Under the revised version, states would have to describe how their health plans "shall maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions." The original language said each state had to show how it "intends" to have adequate and affordable access to coverage.

The bill continues, however, to give states broad new authority to allow insurance companies to provide skimpier plans with far fewer benefits while charging higher premiums to the sick and the old.

Under the new version, states could let insurers impose deductibles that are higher than the limits set by the Affordable Care Act, or remove the health law’s limits on the costs that an individual family can incur in a year entirely. They could also offer coverage that lacks some of the ACA’s benefits, such as maternity care, prescription drugs or mental health. Plus, states could let insurers widen the gap between how much old people and young people are charged. And states could remove requirements that insurers cover preventive-health treatments and immunizations.

Democrats swiftly criticized the latest version.

“Despite an attempt to appear to add money for a select few states, this bill is just as bad for those states and the rest of the states because it still contains a massive cut to Medicaid, and would throw our health insurance system into chaos while raising premiums,” Senate Minority Leader Chuck Schumer said in a statement late Sunday.

“No last-minute changes can disguise the fundamentally rotten consequences of Trumpcare,” House Minority Leader Nancy Pelosi said in a statement Monday. “Republicans must stop making a dangerous bill even worse and join Democrats for constructive bipartisan progress to improve and update Americans’ health care.”

McCain’s ‘Conscience’

The GOP’s hopes for repealing Obamacare were largely dashed on Friday, when Republican Senator John McCain came out against the last-ditch repeal bill.

“I cannot in good conscience vote for the Graham-Cassidy proposal,” McCain of Arizona said in a statement. “I believe we could do better working together, Republicans and Democrats, and have not yet really tried.”

McCain joined Paul in opposing the bill, while Susan Collins of Maine said Sunday she doesn’t see herself backing the bill. “It’s very difficult for me to envision a scenario where I end up voting for this bill,” Collins said on CNN’s “State of the Union.” “I have a number of serious reservations about it.”

Murkowski, who voted against previous repeal measures, is also undecided. Ted Cruz of Texas said Sunday he doesn’t back the bill in its current form, and a few other senators have been silent on their positions including Mike Lee of Utah, Rob Portman of Ohio and Shelley Moore Capito of West Virginia. Senate Republicans can afford to lose no more than two members of their 52-48 majority and pass the bill.

United Opposition

The bill provoked an unusually strong backlash from the health-care industry as well. Groups representing doctors, hospitals and insurers signed a letter Saturday urging the Senate to reject the Graham-Cassidy bill.

The groups said the bill would undermine protections for patients with pre-existing conditions, result in dramatic cuts to Medicaid and “drastically” weaken the individual insurance markets. The letter was signed by the American Medical Association, the American Academy of Family Physicians, the American Hospital Association, and America’s Health Insurance Plans, which represents major insurers.

The expected failure of this effort would mean that Republican efforts to pass a standalone Obamacare repeal are effectively dead, since the fast-track mechanism known as reconciliation that would allow the GOP to pass a measure with only 50 votes expires Sept. 30.

There are, however, a few scenarios for the GOP to revisit health care later in the year. Republicans are planning to adopt a new budget resolution in the fall that would unlock reconciliation for their plan for a tax overhaul. That resolution is expected to allow room for Obamacare repeal provisions, although trying to combine the two complicated policies might make the overall package even harder to pass.

‘Not Easy’

Senate Finance Chairman Orrin Hatch of Utah said last week that there’s a “chance” of pairing taxes with health-care provisions. “But it’s not easy,” he added.

McConnell still has to decide whether to go through with a vote, which would likely happen Wednesday. While Trump has urged GOP leaders to make every possible effort to repeal Obamacare, some Republicans will be reluctant to take a vote on a bill that many privately are uncomfortable with.

The nonpartisan Congressional Budget Office will release a partial analysis of the Graham-Cassidy proposal as early as Monday. It will examine the proposal’s impact on the federal deficit, but a full review of the effect on U.S. health coverage and costs won’t be ready for weeks.

The Senate Finance Committee will hold the only hearing on the bill Monday afternoon, and it doesn’t plan to vote on the measure. Senate Republicans will have a private lunchtime meeting Tuesday, where GOP leaders can make a last plea for support.

If Republicans go ahead with a vote, it could die a rather unceremonious death. There could be essentially no debate on the Senate floor because the Graham-Cassidy bill is being grafted onto McConnell’s previous bill -- and the time for debate on that measure expired in July.

The Graham-Cassidy bill would turn the money that funds Obamacare into block grants for the states, which would create their own health-care plans for their residents. States that expanded Medicaid under Obamacare would be hardest hit, losing $180 billion from 2020 to 2026, according to the Kaiser Family Foundation, which studied an earlier version of the bill. States that rejected the Medicaid expansion would gain $73 billion. The bill changes how Medicaid is funded from a fixed percentage regardless of total spending to a per-enrollee cost.

The bill also would end the Affordable Care Act’s requirements that individuals have insurance and that most employers provide it, and leave most Obamacare tax increases intact.

21 Million Fewer Insured

The Brookings Institution estimated Friday that the Graham-Cassidy plan would reduce the number of people with health coverage by about 21 million a year from 2020 through 2026.

Schumer praised McCain for his opposition in a statement Friday and said, “I have assured Senator McCain that as soon as repeal is off the table, we Democrats are intent on resuming the bipartisan process.”

After the July defeat of McConnell’s plan, Senate Health Chairman Lamar Alexander and top Democrat Patty Murray of Washington worked on a bipartisan plan to shore up Obamacare’s insurance exchanges, but Alexander of Tennessee said last week that the effort had failed. Murray said in a statement, though, that they “identified significant common ground” but GOP leaders decided to “freeze” the bipartisan effort and push the party’s own plan.